Canyon Oaks Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Canoga Park, California.
- Location
- 22029 Saticoy Street, Canoga Park, California 91303
- CMS Provider Number
- 555822
- Inspections on file
- 57
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Canyon Oaks Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that three cognitively intact residents with diagnoses such as DM, atherosclerosis, fractures, and mixed incontinence were always incontinent of bowel and bladder and required significant assistance with toileting-related ADLs, yet their care plans did not specify the type of bowel and bladder (B&B) retraining program to be used. B&B assessments had identified each as a candidate for Prompted Voiding, Habit Training/Scheduled Voiding, or Bladder Retraining, and care plans included general goals to reduce incontinence episodes, but lacked clear identification of the chosen program and individualized approaches or interventions describing how it would be implemented. During interviews, an MDS nurse and the ADON confirmed that individualized, person-centered B&B retraining care plans had not been developed or implemented for these residents, despite facility policy requiring comprehensive, person-centered care plans based on ongoing assessments.
Three cognitively intact residents with diagnoses including DM, atherosclerosis, fractures, and mixed incontinence were assessed as always incontinent of bowel and bladder and identified as candidates for a Prompted Voiding Program, Habit Training/Scheduled Voiding, or Bladder Retraining. Their MDS assessments showed they required moderate to maximal assistance with toileting-related ADLs and were dependent for toilet transfers. Although each resident’s care plan noted incontinence and set goals to decrease episodes, none of the plans specified which bowel/bladder retraining program would be implemented or detailed individualized interventions. Interviews with an MDS nurse and the ADON confirmed there was no documentation that any toileting or retraining program had been initiated, nor that the residents had been offered, agreed to, or declined participation, despite facility P&P requiring appropriate continence services, scheduled toileting or prompted voiding as appropriate, and documentation of toileting trials in the medical record.
A resident with diabetes and severe cognitive impairment did not receive their prescribed insulin glargine at bedtime, despite their blood sugar being within the ordered parameters. Nursing staff confirmed the omission was due to not fully reading the physician's order, resulting in a failure to provide care in accordance with professional standards and facility policy.
A resident with diabetes, requiring a consistent carbohydrate diet, was served regular gelatin and pudding instead of sugar free options. Both nursing and dietary staff confirmed the desserts did not meet the resident's prescribed dietary needs, and the facility's policy for diabetic diets was not followed.
Surveyors found that clear storage cups of gelatin in the kitchen refrigerator were not consistently labeled or dated according to facility policy, with several cups either unlabeled or only marked as sugar free. The Dietary Supervisor confirmed the labeling lapse, which affected a large number of residents who receive food from the kitchen.
A CNA failed to follow perineal care procedures for a resident with frequent incontinence, using a single wet towel to clean both the front and back perineal areas without rinsing or drying, contrary to facility policy. The resident required extensive assistance due to medical conditions and was at risk for pressure injuries. The CNA acknowledged not following the correct protocol during the observed care.
A CNA failed to perform hand hygiene at required intervals while providing perineal care and assisting with wound dressing changes for a resident with cancer and incontinence. The CNA used the same towel for multiple areas, did not change gloves or sanitize hands after cleaning bowel movement, and only performed hand hygiene before starting and after discarding soiled items, contrary to facility policy.
A resident with dementia and severe cognitive impairment was prescribed Seroquel for psychosis and agitation, but the facility failed to complete required monthly behavioral symptom summaries for five months. Despite physician orders and facility policy mandating ongoing monitoring and documentation, staff did not evaluate or summarize the resident's behavioral symptoms during this period, resulting in a lack of assessment for the continued need and effectiveness of the psychotropic medication.
A resident with dementia and hypertension, prescribed Seroquel for psychosis and agitation, had an episode of physical aggression documented in an SBAR form by an LVN, but the same episode was not recorded in the MAR as required. The LVN acknowledged the error, and the ADON confirmed that accurate shift documentation of behavioral episodes is expected for residents on psychotropic medications, in line with facility policy.
The facility failed to ensure call lights were accessible and promptly responded to for residents, leading to potential delays in care. A resident with a history of falls had her call light out of reach, while another resident's active call light was ignored by the DON. Additionally, a resident with reduced mobility struggled to use the standard call light, highlighting the need for adaptive devices.
The facility failed to create comprehensive care plans for two residents, one requiring oxygen therapy and the other on multiple antibiotics for a UTI. Despite physician orders, the care plans did not address these treatments, as confirmed by staff interviews and record reviews. This oversight contravenes the facility's policy on person-centered care plans.
Two residents in the facility received insulin injections without proper site rotation, contrary to professional standards and facility policy. One resident, with impaired cognition, received repeated injections in the same abdominal area over several days, while another resident, capable of understanding, experienced similar issues. A nurse confirmed the oversight, which deviated from guidelines meant to prevent skin damage.
A LTC facility failed to replace an open medication emergency kit within the required timeframe, leading to potential risks for residents. Additionally, there was a discrepancy in the controlled medication count for a resident, and a resident did not receive their routine medication, Gemtesa, due to unavailability and documentation errors. These deficiencies highlight issues in medication management and documentation practices.
A resident with schizophrenia and depression continued to receive aripiprazole despite a PMHNP's order to discontinue it due to stable symptoms. The facility's records showed the medication was administered daily, contrary to the order, and the resident's MDS indicated no behavioral symptoms justifying its use. The DON confirmed the oversight, acknowledging the risk of unnecessary medication administration.
A facility failed to maintain a medication error rate below five percent, resulting in a 24% error rate for a resident. The LVN crushed and administered medications without a physician's order, contrary to facility policy. The resident, with no documented swallowing issues, received medications inappropriately, as confirmed by the PCP and DON.
A facility failed to prevent significant medication errors by not rotating insulin injection sites for two residents and administering expired medications to two others. Insulin injections were repeatedly given in the same area, contrary to policy, and expired insulin and eye drops were administered, violating storage and labeling protocols. These actions were confirmed by staff and highlighted in the facility's policies.
A facility failed to properly label and store medications, including a Forteo pen, insulin Lantus pen, and other medications, leading to potential risks for residents. Medications were found without open date labels or pharmacy labels, and some were expired. Staff acknowledged these issues, highlighting the importance of proper labeling and disposal to ensure medication efficacy and resident safety.
The facility failed to document food temperatures on the tray line, risking food safety for 143 residents. The ADS took temperatures of various foods but did not record some, confirmed by the DS and DON. This omission violated the facility's policy and posed a risk of foodborne illness.
A facility failed to follow infection control and safety protocols, including leaving a leftover muffin in a resident's room, not labeling oxygen tubing, and neglecting hand hygiene during wound care and medication administration. These deficiencies were observed in multiple residents, increasing the risk of infection and foodborne illness.
A facility failed to maintain a resident's Living Will in the medical record, despite the resident's Advance Directive Acknowledgement Form indicating its existence. The resident, with intact cognitive skills and requiring partial assistance, had diagnoses including atrial fibrillation and heart failure. Interviews revealed that the facility did not follow its policy to obtain and maintain the Living Will, risking the resident's end-of-life treatment preferences not being honored.
A facility failed to notify a resident's representative when a medication was no longer covered by insurance, leading to a lapse in administration. Additionally, another resident's family was not informed of a MRSA diagnosis, despite the implementation of contact precautions. These deficiencies highlight communication breakdowns in notifying family members of significant changes in residents' conditions.
A facility failed to transmit a resident's MDS assessment to CMS within the required timeframe following discharge. The resident, who had a periprosthetic fracture, osteoarthritis, and type 2 diabetes, required moderate assistance for daily activities. The MDSC and DON confirmed the oversight, acknowledging the necessity of timely submission to prevent delays in care and payment.
A resident at high risk for falls had a care plan that was not updated to reflect the need for bilateral landing mats, as required by the facility's policy. Despite the resident's severe cognitive impairment and dependency on staff, only one mat was used, increasing the risk of injury. Interviews with facility staff confirmed the lack of proper assessment and implementation of the intervention.
A resident with hearing loss was unable to communicate effectively due to a malfunctioning hearing aid, which was not reported by staff as required by facility policy. The ADON confirmed that the resident's communication was impaired, potentially delaying necessary care.
A resident with cognitive impairments and specific activity preferences was not provided with outdoor activities for two months, despite the facility's policy to cater to individual preferences. The Activity Director acknowledged the oversight, which was contrary to the resident's documented preference for outdoor activities.
A resident with a stage 2 pressure ulcer did not receive continuous treatment as required. The treatment nurse failed to notify the physician before the treatment stop date, resulting in a lapse in care. The facility's policy required contacting the physician to determine if treatment should continue, which was not done, potentially worsening the ulcer.
A resident, assessed as unsafe to self-administer medications, was found with Diclofenac Gel at the bedside, brought by a family member without proper assessment or physician's order. Additionally, the resident, at high risk for falls, had only one floor mat instead of the required two, as per the care plan. The facility's policies on medication self-administration and fall prevention were not followed, leading to potential risks.
A resident with respiratory failure and hypoxia did not receive oxygen as per the physician's order. The nasal cannula was found under the resident's gown instead of being connected, despite the oxygen concentrator being on. This oversight was confirmed by an RN and acknowledged by the DON, highlighting a deficiency in providing necessary respiratory care.
A facility failed to follow its pain management protocols for a resident with cancer and gout, resulting in missed pain assessments after changes in condition and incomplete documentation of pain evaluations. The resident experienced constant pain, but the facility did not conduct required assessments or monitor pain on specific dates, as confirmed by a registered nurse.
A facility failed to document post-dialysis assessments for a resident with end-stage renal disease, omitting vital signs and access site evaluations on two occasions. This oversight, acknowledged by the ADON, could lead to undetected complications such as bleeding, contrary to the facility's care policy.
A facility failed to act on a Consultant Pharmacist's recommendation to administer Ferrous Sulfate to a resident with anemia. The Quality Assurance Nurse did not communicate the recommendation to the physician, resulting in no action being taken. This oversight placed the resident at risk for untreated anemia, as the facility's policy requires monthly medication reviews to promote positive outcomes.
A facility failed to maintain accurate EMAR for a resident prescribed Gemtesa for overactive bladder. Between February 11 and February 19, licensed nurses inconsistently documented the medication's administration, leading to inaccurate records. The resident, with a history of Alzheimer's and Parkinson's, experienced discrepancies in medication availability and charting. Interviews revealed errors by LVNs, highlighting the importance of accurate documentation per facility policy.
A facility failed to create a person-centered care plan for a resident with gastrointestinal atony, leading to a deficiency. The resident, with diagnoses of pneumonia and cerebral infarction, required maximum assistance with daily activities. Despite a physician's order for a KUB X-ray revealing an ileus and a recommendation for increased mobility, the facility did not develop a care plan to address this condition, violating their policy.
A resident with intact cognition reported being run over by another resident's wheelchair, but the incident was not reported within the required two-hour timeframe. The LPN who received the report did not immediately inform the ADM or DON, believing it was only an attempt. The facility's policy mandates prompt reporting of all abuse allegations to ensure resident safety, but the report to the SSA was delayed.
A resident with a history of stroke, atrial fibrillation, and hypertensive heart disease experienced elevated blood pressure. The facility staff failed to notify the physician immediately and did not complete a Change of Condition Form, as required by the facility's policy.
The facility staff failed to re-check and monitor a resident's elevated blood pressure after administering Cardizem LA. Despite the resident's significant medical history, there was no documentation of follow-up monitoring, placing the resident at risk for further episodes of elevated blood pressure.
Failure to Develop and Implement Individualized Bowel and Bladder Retraining Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans for bowel and bladder (B&B) retraining for three residents who were assessed as candidates for such programs. For Resident 2, the admission record showed diagnoses including atherosclerosis of the aorta, lumbar vertebral fracture, low back pain, and mixed incontinence. The MDS documented intact cognition, a need for moderate to maximal assistance with toileting-related ADLs, and that the resident was always incontinent of bowel and bladder. A B&B continence assessment identified the resident as a candidate for Prompted Voiding, Habit Training/Scheduled Voiding, or Bladder Retraining. However, the care plan on toileting and incontinence, while noting risk for incontinence-associated dermatitis and a goal to decrease incontinence episodes, did not specify which B&B retraining program would be used or include individualized approaches or interventions describing how the program would be carried out. Resident 3’s admission and assessment information showed diagnoses including diabetes mellitus and reduced mobility, intact cognitive skills for daily decision making, and a need for maximal assistance or dependence for toileting hygiene, showering, lower body dressing, and toilet transfers. The MDS indicated the resident was always incontinent of both bladder and bowel, and the B&B assessment identified the resident as a candidate for Prompted Voiding, Habit Training/Scheduled Voiding, or Bladder Retraining. The care plan reports, initiated and later revised, documented that the resident was incontinent of bowel and bladder and set goals to decrease urinary and bowel incontinence episodes. Despite this, the care plans did not identify the specific type of B&B retraining program to be implemented and did not include individualized approaches or interventions outlining how the retraining program would be implemented. Resident 4’s records showed admission with diagnoses including atherosclerosis of the aorta, left femur fracture, and presence of a left artificial hip joint. The MDS documented intact cognition, a need for maximal assistance with toileting hygiene and showering, dependence for lower body dressing and toilet transfers, and that the resident was always incontinent of bowel and bladder. A B&B assessment again identified candidacy for Prompted Voiding, Habit Training/Scheduled Voiding, or Bladder Retraining. The care plan, which noted bowel and bladder incontinence and a goal to decrease incontinence episodes during the retraining period, did not specify which B&B retraining program would be used and did not include specific, individualized approaches or interventions. During interviews and record reviews, the MDS nurse and the ADON acknowledged that individualized, person-centered care plans addressing B&B retraining programs, including the type of program and specific interventions, had not been developed and implemented for these three residents, despite facility policy requiring comprehensive, person-centered care plans based on ongoing assessments.
Failure to Implement and Document Individualized Bowel/Bladder Retraining Programs
Penalty
Summary
The deficiency involves the facility’s failure to implement its own policies and procedures for assessment and management of urinary and fecal incontinence for three cognitively intact residents who were always incontinent of bowel and bladder. Resident 2 was admitted with diagnoses including atherosclerosis of the aorta, lumbar vertebral fracture, low back pain, and mixed urinary incontinence. An MDS showed intact cognitive skills and a need for moderate to maximal assistance with toileting-related ADLs, with total dependence for toilet transfers, and documented that the resident was always incontinent of bowel and bladder. A bowel/bladder continence assessment identified the resident as a candidate for a Prompted Voiding Program, Habit Training/Scheduled Voiding, or Bladder Retraining, but did not specify which program would be used or any individualized interventions. The care plan for toileting and incontinence risk noted a goal to decrease incontinence episodes but likewise did not identify a specific retraining program or individualized approaches. Resident 3, originally admitted with diabetes mellitus and reduced mobility, also had an MDS indicating intact cognitive skills, maximal assistance needs for toileting hygiene and showering, dependence for lower body dressing and toilet transfer, and that the resident was always incontinent of bowel and bladder. A bowel/bladder assessment again identified candidacy for Prompted Voiding, Habit Training/Scheduled Voiding, or Bladder Retraining. However, the care plan, which documented that the resident was always incontinent of bowel with a goal to decrease bowel incontinence episodes, did not specify which bowel/bladder retraining program would be implemented or outline individualized interventions or approaches for carrying out such a program. Resident 4 was admitted with atherosclerosis of the aorta, a left femur fracture, and a left artificial hip joint. The MDS documented intact cognitive skills, maximal assistance needs for toileting hygiene and showering, dependence for lower body dressing and toilet transfer, and that the resident was always incontinent of bowel and bladder. The bowel/bladder assessment identified the resident as a candidate for Prompted Voiding, Habit Training/Scheduled Voiding, or Bladder Retraining, and the care plan included a goal to decrease incontinence episodes during a retraining period. Despite this, the care plan did not specify which retraining program would be used or any individualized interventions. Interviews with the MDS nurse and the ADON confirmed there was no documentation that any bowel/bladder retraining program had been implemented for these residents, nor any documentation that the residents had been offered, agreed to, or declined participation, despite facility policies requiring appropriate continence services, scheduled toileting or prompted voiding as indicated, and documentation of toileting trials and programs in the medical record.
Failure to Administer Insulin as Prescribed
Penalty
Summary
A deficiency occurred when a resident with a history of type 2 diabetes mellitus, cerebral infarction, and long-term insulin use did not receive their prescribed insulin glargine as ordered by the physician. The resident, who had severe cognitive impairment and required significant assistance with daily activities, had a physician's order for insulin glargine to be administered at bedtime if their blood sugar was not less than 100 mg/dL. On the date in question, the resident's blood sugar was recorded at 100 mg/dL, which was within the parameters for administration, but the insulin was not given. Interviews with nursing staff revealed that the omission was due to the nurse overlooking the parameters of the order and not reading it in its entirety. Both the registered nurse and the assistant director of nursing confirmed that the medication should have been administered according to the physician's order and facility policy, which requires medications to be given as prescribed. The facility's policy also emphasizes the importance of administering medications in a safe and timely manner, in accordance with prescriber orders.
Diabetic Resident Served Non-Compliant Desserts
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus, who was on a consistent carbohydrate/no added salt diet and required substantial assistance with daily activities, was served regular gelatin and regular pudding instead of sugar free alternatives. The resident's care plan specifically indicated the need for dietary restrictions and compliance with a nutritional regimen to manage hyperglycemia. During lunch service, the gelatin provided was unlabeled, and the pudding cup was marked with an 'R', which staff confirmed indicated regular pudding. Both a Licensed Vocational Nurse and the Registered Dietician verified that the items served were not sugar free and did not meet the dietary requirements for a diabetic resident. The facility's policy on consistent carbohydrate diets, which is intended for residents with diabetes, was not followed in this instance. The Registered Dietician stated that the resident should have received sugar free gelatin and pudding in accordance with their prescribed diet. The failure to provide the appropriate diet was observed during meal service and confirmed through interviews and record review, demonstrating noncompliance with the resident's care plan and facility dietary policies.
Failure to Label and Date Prepared Gelatin in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to follow proper food handling practices by not ensuring that clear storage cups of gelatin were labeled and dated according to the facility's policy. During an inspection of the kitchen refrigerator, open food items not in their original packaging were found in clear storage cups, with several cups either unlabeled or only marked with 'SF' for sugar free. The Dietary Supervisor confirmed that 35 cups had no label and 11 were labeled 'SF', and explained that the person preparing the gelatin is responsible for labeling. The facility's policy requires that any food item removed from its original container must be labeled with the specific name of the food and the date it was opened or prepared. This deficiency had the potential to affect 142 out of 148 residents who receive food from the facility's kitchen. The Dietary Supervisor acknowledged the importance of accurate labeling for resident safety and to ensure the correct identification of food items. A review of the facility's policy confirmed the requirement for labeling and dating prepared foods, which was not followed in this instance.
Failure to Follow Perineal Care Protocol for Incontinent Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the facility's perineal care policy and procedures while providing care to a resident who was frequently incontinent of bladder and occasionally incontinent of bowel. The CNA used a single large wet towel to clean both the front perineal area and the anal/buttocks area, folding and reusing the same towel throughout the process. The CNA did not rinse or dry the resident's perineal area during the care. This method did not align with the facility's policy, which requires the use of separate towels with soap and water for different areas, as well as thorough rinsing and drying. The resident involved had a history of malignant neoplasm of the right breast, secondary malignant neoplasm of the brain, and was at risk for developing pressure ulcers or injuries. The resident was dependent on staff for toileting hygiene and required significant assistance with lower body dressing and toilet transfers. The incident was observed by surveyors, and during interviews, the CNA acknowledged awareness of the correct procedures but admitted to not following them during the observed care. The Director of Nursing confirmed the CNA's knowledge of the proper protocol.
Failure to Perform Proper Hand Hygiene During Perineal Care
Penalty
Summary
Certified Nursing Assistant 3 (CNA 3) failed to follow proper infection control practices while providing perineal care to a resident who was dependent on staff for toileting hygiene, had a history of malignant neoplasm of the breast with secondary brain involvement, and was at risk for pressure ulcers. During the observed care, CNA 3 used the same towel to clean both the front perineal area and the anal/buttocks area, refolding it to use different sections, and did not change gloves or perform hand hygiene (HH) after cleaning the resident's bowel movement. CNA 3 then assisted a treatment nurse with wound dressing changes and subsequently changed the resident's brief and clothing, only performing HH after discarding the soiled items. When questioned, CNA 3 acknowledged that she was supposed to wash her hands and change gloves after cleaning the perineal area and before touching the resident's body, new brief, or clothing, but admitted to performing HH only twice during the entire process. The Infection Preventionist confirmed that CNA 3 did not perform HH at the appropriate times as required by facility policy, specifically after contact with body fluids and before moving from a soiled to a clean body site on the same resident. Facility policies reviewed indicated that hand hygiene is the primary means to prevent the spread of healthcare-associated infections and outlined specific requirements for HH during resident care.
Failure to Monitor and Summarize Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications by not evaluating and summarizing the resident's behavioral symptoms for a period of five months while the resident was prescribed Seroquel for psychosis and agitation associated with dementia. The resident, who had severe cognitive impairment and required maximal assistance with daily activities, had a physician's order for Seroquel to be administered at bedtime for psychosis as evidenced by hallucinations or agitation leading to aggression. The order also required monitoring of episodes of psychosis, agitation, aggression, and hallucinations every shift. Despite these requirements, the facility did not complete the required monthly Psychotropic Drug Behavior Monitoring (PDBM) summaries from January through May. The last available PDBM summary was from December of the previous year. Both the Assistant Director of Nursing and the Director of Nursing confirmed that no behavioral symptom summaries were completed during this period and that the facility relied on these summaries to evaluate the effectiveness and necessity of the psychotropic medication. The facility's policy required adequate monitoring and documentation for the use of psychotropic medications, which was not followed in this case.
Failure to Accurately Document Behavioral Episodes in MAR
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the Medication Administration Record (MAR) for a resident with dementia and hypertension. The resident, who had severely impaired cognitive skills and required maximal assistance with daily activities, was prescribed Seroquel for psychosis and agitation. Physician orders required monitoring and documentation of episodes of psychosis, agitation, or aggression every shift. On a specific date, a Licensed Vocational Nurse (LVN) completed an SBAR Communication Form indicating an episode of physical aggression but documented in the MAR that there were no such episodes during the same shift. During interviews and record reviews, the LVN acknowledged the documentation error, stating that the MAR should have reflected the episode of aggression. The Assistant Director of Nursing (ADON) confirmed that licensed nurses are expected to accurately document behavioral episodes in the MAR for residents on psychotropic medications, as per facility policy. The facility's policy emphasized that medical records should be objective, complete, and accurate to facilitate communication among the care team.
Failure to Ensure Call Light Accessibility and Prompt Response
Penalty
Summary
The facility failed to ensure that residents were provided with a call light within reach, which is essential for signaling the need for assistance. Resident 34, who was admitted with conditions such as atherosclerotic heart disease, muscle weakness, and a history of falls, was observed with her call light under the mattress and not within reach. This was confirmed by a Care Partner and a Registered Nurse, both of whom acknowledged the importance of having the call light accessible to prevent delays in care. The facility's policy mandates that call lights be within reach to allow residents to call for help. Resident 134, who had a history of falls and required moderate assistance for daily activities, was observed with an active call light that was not addressed by the Director of Nursing (DON) who walked by the room twice without entering. The DON admitted that the call light should have been addressed immediately to prevent delays in care. The facility's policy requires that call lights be answered as soon as possible, but no later than five minutes. Resident 395, who was admitted with sepsis, major depressive disorder, and reduced mobility, was found unable to reach the call light due to weakness in her hands and arms. The call light was under her pillow, and she demonstrated difficulty using it. A Licensed Vocational Nurse confirmed the resident's inability to use the regular call light and mentioned the availability of adaptive devices. The facility's policy states that alternative communication means should be provided for residents unable to use the standard call system.
Failure to Develop Comprehensive Care Plans for Oxygen and Antibiotic Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to potential inadequate care. Resident 345, who was admitted with chronic obstructive pulmonary disease and acute respiratory failure, required intermittent oxygen therapy. Despite physician orders specifying oxygen administration and equipment maintenance, the facility did not create a care plan addressing the resident's oxygen use. This oversight was confirmed during interviews with a registered nurse and the Director of Nursing, who acknowledged the absence of a care plan with specific goals and interventions for oxygen use. Similarly, the facility did not develop a care plan for Resident 27's antibiotic use, despite multiple physician orders for antibiotics to treat a urinary tract infection. The resident, who had diagnoses including acute respiratory failure and type 2 diabetes, was prescribed several antibiotics, but the care plans did not reflect this treatment. The Minimum Data Set Coordinator and the Director of Nursing confirmed the lack of a care plan addressing the antibiotic administration, which is crucial for providing specific interventions related to these medications. The facility's policy and procedure on comprehensive person-centered care plans require the development of care plans based on thorough assessments and clinical decision-making. However, the facility did not adhere to these guidelines, resulting in the failure to create necessary care plans for the residents' oxygen and antibiotic use. This deficiency was identified through interviews and record reviews, highlighting the facility's non-compliance with its own policies.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that insulin injections were administered in accordance with professional standards of practice by not rotating the injection sites for two residents. Resident 76, who was admitted with diagnoses including type 2 diabetes mellitus, neuropathy, and major depressive disorder, received insulin injections repeatedly in the same area of the abdomen over several days in February 2025. This practice was contrary to the facility's policy and the manufacturer's guidelines, which require rotation of injection sites to prevent skin damage and medication errors. Similarly, Resident 111, who was admitted with type 2 diabetes mellitus and major depressive disorder, also received insulin injections in the same area of the abdomen multiple times in December 2024. Despite having the capacity to understand and make decisions, the resident's insulin administration did not adhere to the recommended practice of site rotation. The facility's policy and the medication insert instructions both emphasize the importance of rotating injection sites to avoid adverse effects such as lipodystrophy and localized cutaneous amyloidosis. During interviews and record reviews, a registered nurse acknowledged the failure to rotate injection sites for both residents, highlighting a deviation from the facility's procedures and professional standards. The facility's policies on adverse consequences and medication errors, as well as insulin administration, clearly outline the necessity of site rotation to prevent skin tissue damage and ensure proper medication administration.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to replace an open medication emergency kit within the required 72-hour timeframe. During an observation, it was noted that the kit, labeled B002, was opened on February 13, 2025, and had not been replaced by February 24, 2025. This oversight was acknowledged by RN 1, who stated that the kit should have been replaced within 24 hours, as per facility policy, to ensure emergency medications are available when needed. Additionally, there was a discrepancy in the controlled medication count for a resident, where one dose of pregabalin was missing from the medication bubble pack compared to the Controlled Drug Record accountability log. LVN 4 admitted to administering the medication but failing to document it, which is against the facility's policy. This lack of documentation could lead to medication errors and potential harm to the resident. The facility also failed to provide a resident with their routine medication, Gemtesa, for over a week due to unavailability. Despite the medication being marked as administered in the EMAR, it was confirmed by LVNs that the medication was not available during that period. This error in documentation and follow-up resulted in the resident not receiving their prescribed medication, which could have worsened their condition.
Failure to Discontinue Unnecessary Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically concerning the administration of an antipsychotic medication, aripiprazole. The resident, who had a diagnosis of schizophrenia and depression, was prescribed aripiprazole 5 mg to be administered as 2.5 mg daily. Despite a Psychiatric Mental Health Nurse Practitioner's (PMHNP) order on January 24, 2025, to discontinue the medication due to the stability of the resident's psychosis symptoms, the medication continued to be administered daily until February 18, 2025. The Minimum Data Set (MDS) for the resident, dated February 4, 2025, indicated that the resident was moderately impaired in cognitive skills for daily decision-making and had no mood or behavioral symptoms such as screaming. The MDS also noted that a Gradual Dose Reduction (GDR) was attempted on February 2, 2025, but there was no documentation from a physician indicating that the GDR was clinically contraindicated. Despite the PMHNP's note on February 7, 2025, indicating no apparent distress after discontinuing the medication, the facility's Medication Administration Record (MAR) showed that the resident continued to receive the medication daily. During a review and interview with the Director of Nursing (DON) on February 26, 2025, it was confirmed that the facility failed to discontinue the medication as per the PMHNP's orders. The DON acknowledged that the resident did not exhibit any documented behaviors that would justify the continued use of the medication, aligning with the PMHNP's orders to attempt a GDR by discontinuing aripiprazole. This oversight placed the resident at risk of receiving unnecessary psychotropic medications, which could result in adverse consequences and side effects, negatively impacting the resident's health and well-being.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to ensure that the medication error rate was less than five percent, resulting in a 24% error rate for one resident during medication administration. Six out of 25 medication opportunities were administered incorrectly to a resident, as the medications were crushed and mixed with applesauce without a physician's order to do so. The Licensed Vocational Nurse (LVN) involved acknowledged the error, stating that medications should only be crushed with a physician's order, and admitted to not contacting the physician to obtain such an order. The resident involved, who was admitted with diagnoses including dementia, atherosclerosis, and hypertension, did not have any documented difficulty swallowing. The primary care physician confirmed that there were no orders to crush the medications and was unaware of any swallowing issues. The facility's policy requires medications to be administered according to prescriber orders and specifies that medications should only be crushed when appropriate and consistent with physician orders. The Director of Nursing confirmed that the LVN failed to follow the facility's policy by crushing the medications without an order.
Significant Medication Errors in Insulin Administration and Expired Medications
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the improper administration of insulin and expired medications. Two residents, both diagnosed with type 2 diabetes mellitus, were subjected to repeated insulin injections in the same area without site rotation, contrary to the facility's policy and professional standards. This practice was observed in the medication administration records of both residents, with injections consistently administered in the left upper quadrant of the abdomen for one resident and the left lower quadrant for the other. The failure to rotate injection sites was acknowledged by a registered nurse during a review, who confirmed that this constituted a medication error. Additionally, the facility administered expired medications to two residents. One resident received a dose of expired insulin Fiasp, while another received two doses of expired latanoprost eye drops. The expired medications were found in a medication cart, improperly stored and labeled, and were administered by licensed vocational nurses. The facility's policies and procedures, as well as manufacturer instructions, were not followed, leading to the administration of these expired medications. The Director of Nursing confirmed that the facility failed to dispose of expired medications as per policy, which could result in decreased potency and effectiveness of the medications. The facility's policies on medication administration and storage were not adhered to, resulting in significant medication errors. The policies clearly outlined the need for rotating injection sites and discarding expired medications, yet these were not followed, leading to the deficiencies observed. The report highlights the facility's failure to comply with professional standards and its own procedures, resulting in potential harm to the residents involved.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and store medications in accordance with manufacturers' requirements and facility policies, leading to potential risks for residents. During an observation in Medication Room Station 2, a Forteo pen for a resident was found without an open date label, contrary to the manufacturer's instructions to discard the pen 28 days after first use. This oversight was acknowledged by RN 1, who confirmed the importance of labeling to prevent the use of ineffective medication. In Medication Room Station 1, an insulin Lantus pen was discovered without a pharmacy label, making it unclear which resident it belonged to. LVN 3 confirmed that facility policy requires all medications to be labeled with the resident's name to prevent accidental administration to the wrong resident. The lack of labeling posed a risk of medication errors and potential transmission of blood-borne pathogens. Further deficiencies were noted in Medication Cart 2 Station 4, where several medications were either improperly labeled or expired. A fluticasone and salmeterol inhalation powder device for a resident was not labeled with an open date, making it impossible to determine its expiration. Additionally, an expired Fiasp Flextouch pen and latanoprost eye drop bottle were found, both of which had been used beyond their recommended dates. LVN 5 acknowledged these issues, emphasizing the importance of proper labeling and timely disposal to ensure medication efficacy and resident safety.
Failure to Document Food Temperatures on Tray Line
Penalty
Summary
The facility failed to ensure proper documentation of food temperatures on the tray line, which is crucial for maintaining food safety standards. During an observation, the Assistant Dietary Supervisor (ADS) was noted to have taken temperatures of various food items, including soup, beef, vegetables, and others, but failed to record the temperatures of fish, cottage cheese, diced chicken, beans, and mashed potatoes. This omission was confirmed during an interview and record review with the ADS, who acknowledged that these temperatures should have been documented to ensure food safety and prevent potential foodborne illnesses. The Dietary Supervisor (DS) and the Director of Nursing (DON) both emphasized the importance of maintaining a complete Food Temperature Log to ensure that all food served is within the safe temperature range. The facility's policy, last reviewed in January 2025, mandates that food temperatures be taken and recorded before meal service. The failure to document these temperatures posed a risk to the 143 medically compromised residents who rely on the facility's kitchen for their meals, as it could lead to harmful bacteria growth and cross-contamination, potentially resulting in foodborne illnesses.
Infection Control and Safety Protocol Failures
Penalty
Summary
The facility failed to ensure proper food safety protocols were followed for a resident, identified as Resident 96, who was found with a leftover blueberry muffin from the previous day on their bedside table. The muffin was uncovered and exposed to air, which could lead to contamination and potential foodborne illness if consumed. The Dietary Supervisor confirmed that leftover food should be discarded after two hours to prevent such risks, but the muffin remained in the resident's room beyond this time frame. Another deficiency was observed in the facility's failure to adhere to their oxygen administration policy for Resident 345. The resident's oxygen tubing was not labeled with the date and time of the last change, as required by the facility's procedures. This oversight was acknowledged by both a Certified Nursing Assistant and a Licensed Vocational Nurse, who confirmed that the tubing should be changed weekly and labeled accordingly to prevent infection risks. The facility also did not comply with hand hygiene protocols during wound care for Resident 32. Treatment Nurse 2 failed to use alcohol-based hand rub after removing gloves, which is a critical step in preventing the spread of infection. Additionally, a Licensed Vocational Nurse did not perform hand hygiene before preparing and administering medication to another resident, further increasing the risk of infection spread. These lapses in infection control practices were acknowledged by the facility's Infection Preventionist and Director of Nursing, who emphasized the importance of following established hand hygiene procedures.
Failure to Maintain Resident's Living Will in Medical Record
Penalty
Summary
The facility failed to implement its policy and procedure for Advance Directives for one of the sampled residents by not obtaining and maintaining a copy of the resident's Living Will in the medical record. The resident, who was originally admitted in 2017 and readmitted later, had diagnoses including weakness, atrial fibrillation, and heart failure. The Minimum Data Set indicated that the resident's cognitive skills for daily decision-making were intact, and the resident required partial assistance for certain activities. The Advance Directive Acknowledgement Form, signed by the resident's Responsible Party, indicated that the resident had executed a Living Will and provided it to the facility. Interviews with the Social Worker and the Director of Social Services revealed that the facility did not have a copy of the resident's Living Will in the medical chart, despite the acknowledgment form indicating its existence. The facility's policy required that copies of Advance Directives be obtained and maintained in the resident's medical record in a readily retrievable location. The failure to have the Living Will in the medical chart meant that the resident's end-of-life treatment preferences might not be honored, as the staff would not be aware of the resident's wishes.
Failure to Notify Resident Representatives of Medication and Condition Changes
Penalty
Summary
The facility failed to notify the resident's representative when a resident's medication, Gemtesa, was no longer covered by insurance and before it ran out. This affected Resident 112, who had been admitted with diagnoses including Alzheimer's Disease, Parkinson's Disease, and major depressive disorder. The medication was crucial for managing urinary incontinence, and its discontinuation without notification had the potential to negatively impact the resident's care. The Licensed Vocational Nurse (LVN) documented the medication as not available and awaiting refill, but the family was not informed until several days later, leading to a lapse in medication administration. In another instance, the facility failed to notify a resident's representative of a change in condition when Resident 27 was diagnosed with Methicillin-Resistant Staphylococcus aureus (MRSA). Despite the diagnosis and the implementation of contact precautions, the family member was only informed of a urinary tract infection and a room change, not the MRSA diagnosis. This lack of communication was confirmed through interviews with staff, including Licensed Vocational Nurses and the Social Worker, who acknowledged the oversight in notifying the family about the MRSA diagnosis. The facility's policy and procedure require prompt notification of changes in a resident's medical condition to the resident, their physician, and their representative. However, in both cases, this policy was not followed, leading to deficiencies in communication and potential negative impacts on the residents' care. The failure to notify the family members about significant changes in the residents' conditions highlights a breakdown in the facility's communication processes.
Failure to Timely Transmit MDS Assessment
Penalty
Summary
The facility failed to ensure the timely transmission of the Minimum Data Set (MDS) assessment to the Centers for Medicare and Medicaid Services (CMS) system for a resident, identified as Resident 30. The resident was admitted with diagnoses including a periprosthetic fracture around an internal prosthetic left knee, osteoarthritis, and type 2 diabetes. The resident required moderate assistance for all activities of daily living and had mildly impaired cognition. Despite these needs, the MDS assessment, which is required to be completed and submitted within 14 days of discharge, was not completed or submitted to CMS following the resident's discharge. Interviews with the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON) confirmed the oversight. The MDSC acknowledged the requirement to complete the MDS assessment upon discharge and admitted that the assessment for Resident 30 was neither completed nor submitted. The DON reiterated the necessity of submitting the discharge assessment within the stipulated timeframe to avoid delays in care and payment. The facility's failure to adhere to these requirements was identified as a deficiency, with the potential to delay services for the resident.
Failure to Revise Care Plan for Fall Risk Resident
Penalty
Summary
The facility failed to revise a resident's care plan to accurately reflect the use of floor or landing mats for a resident at high risk for falls. The resident, who was severely impaired in cognition and dependent on staff for dressing and footwear, had a history of falls and was identified as high risk for falls in a Fall Risk Evaluation. Despite this, the care plan initially included only one landing mat, contrary to the intervention added to the care plan which indicated the need for mats on both sides of the bed. This discrepancy was observed during an interview and record review, where it was noted that only one mat was being used, and there was no current order for any landing mat. The deficiency was further highlighted during interviews with facility staff, including a CNA, LVN, ADON, and DON, who confirmed the lack of proper assessment and implementation of the intervention for bilateral landing mats. The facility's policy on fall prevention and comprehensive person-centered care plans emphasized the need for thorough assessment and appropriate interventions, which were not followed in this case. The failure to update the care plan and implement the necessary interventions increased the risk of injury for the resident in the event of a fall.
Failure to Maintain Resident's Hearing Aid Functionality
Penalty
Summary
The facility failed to ensure that a resident's hearing aid was functioning properly, which impacted the resident's ability to communicate effectively. The resident, who was admitted with diagnoses including muscle weakness and hearing loss, was observed stating that her hearing aid was broken and that she could not hear. Despite the Minimum Data Set (MDS) indicating that the resident could hear adequately with a hearing aid, the resident repeatedly reported the malfunction to staff, including the Assistant Director of Nursing (ADON) and a Certified Nurse Assistant (CNA). The ADON acknowledged that the resident's ability to communicate needs to caregivers was compromised due to the malfunctioning hearing aid. The facility's policy required staff to notify a supervisor if a hearing aid was damaged, but there was no record of such a report being made to the Social Services Department. This oversight had the potential to delay necessary care, treatment, or services for the resident.
Failure to Provide Resident with Preferred Outdoor Activities
Penalty
Summary
The facility failed to provide activities according to the preferences of a resident, identified as Resident 98, which resulted in a deficiency. Resident 98 was admitted with diagnoses including hepatomegaly and benign prostatic hyperplasia. The Minimum Data Set (MDS) assessment indicated that the resident had severely impaired cognitive skills and required maximal assistance for daily activities. Importantly, the MDS noted that it was important for the resident to go outside for fresh air when the weather was good. Despite this preference, the Activity Director (AD) confirmed during an interview and record review that Resident 98 had not participated in outdoor activities for the past two months. The facility's policy on Activity Programs, which was last reviewed in January 2025, stated that activities should be designed to meet the interests and well-being of each resident based on their preferences. The AD acknowledged that outdoor activities were beneficial for the resident's well-being and should have been provided, indicating a failure to adhere to the resident's activity preferences.
Failure to Continue Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide care consistent with professional standards for a resident with a stage 2 pressure ulcer in the sacral region. The resident, who had severe cognitive impairment and required maximal assistance for daily activities, was admitted with this condition. A physician's order was in place to treat the ulcer with normal saline, zinc oxide, and a dry dressing for 21 days. However, the treatment was discontinued on the 21st day without notifying the physician, even though the ulcer had not fully healed. The treatment nurse did not inform the physician before the treatment stop date, resulting in a lapse in care from the 22nd to the 30th day. The treatment was only resumed on the 31st day and continued for six days. The facility's policy required the nurse to contact the physician one day before the treatment stop date to determine if the treatment should continue, which was not done. This oversight had the potential to worsen the pressure ulcer and lead to infection.
Failure to Prevent Medication Mismanagement and Inadequate Fall Prevention
Penalty
Summary
The facility failed to ensure that a resident, who was assessed as unsafe to self-administer medications, was not left unattended with Diclofenac Gel 1% at the bedside. The resident, who was severely impaired in cognition and dependent on staff for daily activities, was observed with the medication on the bedside table. The Licensed Vocational Nurse (LVN) and Treatment Nurse (TN) were unable to locate the medication in the medication cart, and it was revealed that the resident's family member had brought the medication to the facility. The facility's policy required an assessment and physician's order for self-administration, which was not completed for this resident. Additionally, the facility failed to provide adequate fall prevention measures for a resident at high risk for falls. The resident's care plan indicated the need for floor mats on both sides of the bed, but only one mat was observed in use. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the resident required two landing mats due to a previous fall and the potential to fall on either side when attempting to get out of bed. The facility's policies on self-administration of medications and fall prevention were not followed, leading to potential risks for the resident. The interdisciplinary team did not assess the resident's ability to self-administer medication, and the necessary fall prevention interventions were not fully implemented, as evidenced by the observations and interviews conducted during the survey.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care to Resident 136, who was admitted with diagnoses including respiratory failure with hypoxia, heart failure, and parkinsonism. The physician's order required oxygen administration at two liters per minute via nasal cannula as needed to maintain oxygen saturation above 90%. However, during an observation, it was found that the nasal cannula was not connected to the resident but was instead under the resident's gown, while the oxygen concentrator was on. This oversight was confirmed by RN 2, who acknowledged the need for oxygen administration to maintain the resident's oxygen saturation levels. The Director of Nursing confirmed that oxygen should be administered according to the physician's order to prevent the worsening of the resident's respiratory condition. The facility's policy on oxygen administration emphasized the importance of securely anchoring the tubing and ensuring the proper placement of the oxygen device on the resident. The failure to adhere to these guidelines and the physician's order resulted in a deficiency in providing necessary respiratory care to Resident 136, potentially impacting the resident's respiratory well-being.
Failure to Follow Pain Management Protocols
Penalty
Summary
The facility failed to adhere to its policy and procedure for pain assessment and management for a resident, identified as Resident 38, who was admitted with diagnoses including secondary malignant neoplasm of bone and peritoneum, and gout. The resident's Minimum Data Set (MDS) indicated that they experienced almost constant pain over a five-day period and were dependent on staff for various activities of daily living. Despite this, the facility did not conduct pain assessments following changes in the resident's condition on two occasions, specifically on 12/8/2024 and 2/13/2025, when the resident experienced new or worsening pain. Additionally, the facility did not thoroughly complete the Pain Risk Evaluation form for Resident 38 on 12/30/2024. The form failed to include the names of both scheduled and PRN medications used for the resident, which is a requirement for a complete assessment. Furthermore, the facility did not monitor the resident for the presence of pain on two specific dates, 2/7/2025 and 2/23/2025, during the evening shift, as indicated by the absence of entries in the Medication Administration Record (MAR). During an interview, a registered nurse confirmed these deficiencies, acknowledging that the licensed staff did not develop and complete pain risk evaluations after the resident's changes in condition and failed to document pain monitoring as required. The facility's policy mandates comprehensive pain assessments upon admission, quarterly, and whenever there is a significant change in condition, which was not followed in this case.
Failure to Document Post-Dialysis Assessments
Penalty
Summary
The facility failed to complete the Hemodialysis Communication Record for a resident requiring dialysis services, specifically omitting post-dialysis assessments of the access site and vital signs. This deficiency was identified during a review of the resident's records and an interview with the Assistant Director of Nursing (ADON). The resident, who was admitted with end-stage renal disease and impaired cognitive skills, had an order for dialysis treatment three times a week. However, on two specific dates, the required post-dialysis assessments were not documented, which is a critical step in monitoring for potential complications such as redness, swelling, drainage, or prolonged bleeding at the access site. The ADON acknowledged the importance of these assessments, noting that failure to perform them could lead to undetected complications, potentially resulting in negative outcomes like bleeding and hemorrhage. The facility's policy on the care of residents with end-stage renal disease, last reviewed in January 2025, mandates adherence to recognized standards of care, including post-dialysis assessments. The omission of these assessments represents a deviation from the facility's established procedures and places the resident at risk for serious health issues.
Failure to Act on Pharmacist's Recommendation for Anemia Treatment
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist's recommendation for a Medication Regimen Review (MRR) was discussed with the physician and acted upon for a resident diagnosed with anemia. The Consultant Pharmacist recommended administering Ferrous Sulfate, an iron supplement, to stimulate erythropoiesis. However, the Quality Assurance Nurse (QAN), responsible for communicating these recommendations to the physician, did not discuss this recommendation with the physician, as there was no documentation indicating that the recommendation was acted upon or that the physician disagreed with it. The resident, who was originally admitted in 2020 and readmitted later, had a diagnosis of anemia, among other conditions. The resident required maximal assistance with daily activities and had the ability to communicate and understand others. The facility's policy requires the Consultant Pharmacist to review each resident's medication regimen monthly to promote positive outcomes and minimize risks. The failure to communicate the pharmacist's recommendation placed the resident at increased risk for untreated anemia, which could lead to complications such as fatigue and weakness.
Inaccurate EMAR Documentation for Resident's Medication
Penalty
Summary
The facility failed to maintain accurate electronic medical administration records (EMAR) for a resident, identified as Resident 112, who was prescribed Gemtesa for overactive bladder. The deficiency occurred between February 11, 2025, and February 19, 2025, when licensed nurses did not accurately chart the administration of the medication. The EMAR showed discrepancies where some nurses marked the medication as administered, while others indicated it was on hold due to unavailability. This resulted in inaccurate documentation in the resident's medical record. Resident 112, who was admitted to the facility on June 15, 2023, had a medical history that included Alzheimer's Disease, Parkinson's Disease, major depressive disorder, and a history of falling. The resident's physician had noted improvement in bladder spasms and urination when on Gemtesa, and the medication was to be continued. However, the EMAR entries showed inconsistencies, with some nurses marking the medication as given when it was not available, and others indicating it was on hold due to awaiting a refill from the pharmacy. Interviews with the involved licensed vocational nurses (LVNs) revealed that the medication was not available on certain days, yet it was mistakenly documented as administered. LVN 8 and LVN 9 admitted to errors in charting, acknowledging the importance of accurate documentation. LVN 4 confirmed the medication was unavailable on specific dates and had informed the resident's family about the issue. The facility's policy and procedure on charting and documentation emphasized the need for objective, complete, and accurate records, which was not adhered to in this case.
Failure to Develop Comprehensive Care Plan for Resident with Ileus
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with gastrointestinal atony, which is a condition where the stomach cannot contract normally, leading to delayed movement of food. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, who was originally admitted in October 2023 and readmitted in December 2023, had diagnoses including pneumonia and cerebral infarction. The Minimum Data Set (MDS) indicated that the resident had intact cognition but required maximum assistance with various activities of daily living. On December 14, 2023, a physician's order was made for an immediate KUB X-ray to assess the resident's abdominal pain, which revealed an ileus. The physician was informed of the results and recommended increased mobility for the resident. However, during a review conducted in July 2024, it was found that the facility had not developed a comprehensive care plan to address the resident's ileus condition. This oversight was contrary to the facility's policy, which mandates the creation of a comprehensive, person-centered care plan with measurable objectives and timetables for each resident.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to adhere to its policy and procedures for reporting a reasonable suspicion of a crime, specifically in the case of a physical abuse allegation involving two residents. Resident 1, who had intact cognition, reported to the Social Service Director and Director of Nursing that Resident 2 ran over him with her wheelchair. This incident was reported to have occurred on 6/8/2024, but the initial report was not made within the required two-hour timeframe. Licensed Vocational Nurse 1, who was informed of the incident by Resident 1, did not report it to the Administrator or Director of Nursing immediately, as she believed it was only an attempt and not an actual incident of abuse. The facility's policy requires that all abuse allegations, whether attempted or actual, be reported within two hours to ensure resident safety. However, the allegation was not reported to the State Survey Agency until 6/10/2024, which was beyond the required timeframe. The facility's policy on abuse, neglect, exploitation, or misappropriation, last revised in 9/2022, mandates that all reports of resident abuse be reported to local, state, and federal agencies and thoroughly investigated. The failure to report the incident promptly had the potential to delay necessary actions to protect the residents.
Failure to Notify Physician of Elevated Blood Pressure
Penalty
Summary
The facility staff failed to notify the physician immediately of a change in condition for a resident who experienced an episode of elevated blood pressure. The resident, admitted with diagnoses including cerebral infarction, atrial fibrillation, and hypertensive heart disease with heart failure, had a blood pressure reading of 193/93. Despite this significant elevation, there was no documented evidence that the physician was notified or that a Change of Condition Form was completed. The Director of Nursing confirmed that the licensed nurse should have notified the physician and completed the necessary documentation upon identifying the elevated blood pressure. The resident's Medication Administration Record indicated that the elevated blood pressure was recorded, and the prescribed medication, Cardizem LA, was administered. However, the lack of immediate notification to the physician and the absence of a Change of Condition Form were identified as deficiencies. The facility's policy requires prompt notification of the physician and the resident's representative in the event of a change in medical condition, which was not adhered to in this instance.
Failure to Monitor Elevated Blood Pressure
Penalty
Summary
The facility staff failed to re-check and monitor a change in condition for one resident who experienced an episode of elevated blood pressure. The resident, admitted with diagnoses including cerebral infarction, atrial fibrillation, and hypertensive heart disease with heart failure, had a blood pressure reading of 193/93. Despite administering Cardizem LA as prescribed, there was no documented evidence that the resident's blood pressure was re-checked and monitored 30 minutes to an hour after administration to determine the medication's effectiveness. During an interview and record review, the Director of Nursing confirmed the absence of documentation indicating that the resident's blood pressure was monitored following the administration of the medication. The facility's policy on hypertension management emphasizes the importance of monitoring and documenting blood pressure trends and isolated elevations. The failure to follow this protocol placed the resident at risk for further episodes of elevated blood pressure due to the lack of immediate medical treatment and intervention.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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